Pharma: Nutrition and Electrolytes and Vitamins and Stuff

Nutrition/sElectrolytes

1: Vitamin Supplements
Vitamin Supplements and replacements
inadequate absorbtion; who? IBD [inflame bowel disorder], infections, antibiotics, people w/ diarrhea [from TF, infections, c diff, meds, illness, etc]
inability to use vitamins, why? Liver disease, cirrhosis, renal disease, genetic factors apperently
increased vitamin losses: why? Hypermetabolic state, hyperthyroid, inc vit requirements, infections, diuretics can lose some of these
increased vit requirements: why?

B: fat-soluble vit’s: these are toxic in high doses because they are fat soluble, and are not flushed from the body. Toxicity is called “hypervitaminosis D, E, K, or A”
vit A: skin disorders, bone development, prevent night blindness, Vit A deficiency [pancreatic disease, colitis, cirrhosis, celiac’s.] Stored in liver for up to two years, excreted through kidneys and poop. Don’t eat polar bear liver b/c you’ll OD on Vitamin A and die.

vit D: needed for Calcium absorption from the intestines. Overdose can cause hypercalcemia. Secreted through bile.

Vit E: antioxidant, good for cell membranes. Studies show protection from MI, CAD, by protecting blood vessel walls from free radicals. Good for Skin. May increase PT [monitor w/ coumadin], don’t take with Iron—iron disrupts body use and absorption of Vit E. 75% lost thru bile.

Vit K: good for clotting factors: prothrombin, factors VII, IX, and X. This can be used to prevent hemorrhage anticoagulant overdose. Who is lacking clotting factors: liver makes clotting factors so this is needed for liver disease clients, alcoholics coming in with GI bleed. Aquamephyton: commercial K1 preparation.

C: Water-sol vit’s
Vit B: lots of these B vitamin complex thingies. Given for dermatitis, inflammation. Niacin is Vitamin B3, used to fight off thrush, hyperlipidemia (big doses for that.) Large doses cause vasodilation: flushing or ‘blushing’ sensation.
Vit C/ascorbic acid: green leafy veggies, citrus are not super available in hosp meal trays. Aids in absorption of iron and conversion of folic acid. High doses can cause diarrhea and GI upset. You can’t really overdose on it, but rapid decrease can cause ‘rebound deficiency.’ Treats scurvy [vit c deficiency], good for wound healing and burns. Preserves integrity of blood vessels.

D: RN’ing process
Assess: skin integrity, healing, I/O, diet types, can they advance their diet, lab values (like electrolytes, pre albumin, CBC, platelet counts)

E: Minerals
Iron: need larger amounts during pregnancy. Iron deficiency anemia, Iron is vital fcor hemoglobin regeneration: 60% of the iron in the body is in hemoglobin. Vit C increases iron absorption.

Copper: for formation of RBC’s, connective tissues, enzyme cofactor, neurotransmitter production. Not-enough-copper-syndrome: anemia, decrease in WBC’s, hair color changes, skin and blood abnormalities. Seeds, shellfish, legumes and cocoa are high in copper.

Zinc: Not sure what its good for—maybe the common cold. Don’t take at the same time as an antibiotic—wait a couple hours. Large doses can cause copper deficiency, low HDL, weak immunity.

Chromium: May normalize blood glucose by sensitizing cells to glucose. Interesting in TPN; cancer pts, other pts who can’t use their GI tract [I have no idea why Margi says that.]

Selenium: cofactor for antioxidant enzyme. Works w/ vit E. May have anticarcinogen effect. High doses: weakness, hair loss, dermatitis, GI upset, make you smell like garlic.

RNing process
Assess: nutritional state, dietician, make some calls, ensure they’re tolerating tube feeding, dehydration, loose stools, etc.

II: FLUID/ELECTROLYTE REPLACEMENT
A: Body fluids: only %5 of total body water is in our blood vessels, so if someone is hypovolemic it means they’ve lost interstitial fluid or they’ve got edema.
B: Fluid replacement
IV solutions
Why iv’s: they’re dehydrated, they can’t swallow water
Crystalloids: most are crystalloids, they have dextrose or electrolytes, they are clear.
i. D5W: dextrose [sugar] and water
ii. NS: 0.9% NaCL
iii. LR: Lactated Ringer’s
Colloids: big proteins, they are ‘volume expanders’. These pull water osmotically from the periphery to increase Blood Volume. Needed in septic shock, burn patients, etc. Also need to give IV fluids.
i. Dextran 40: can interfere w/ platelet.
ii. Hetastarch: can decrease platelets, hematocrit
iii. Plasmanate: used to replace body protein

Blood and blood products: why? Not producing enough, lost too much blood, septic, low blood volume. We don’t transfuse very often b/c of blood borne diseases, we killed some people w/ the wrong blood—anaphylactic reaction.
i. Packed RBC’s: whole blood, no plasma—good because less risk circulatory overload, rxns to antigens, risk of transmitting hepatitis. Elevates hematocrit.
ii. Whole Blood: Do not use to correct anemia except in severe cases. Elevates hemoglobin.
iii. Plasma:
iv. Albumin
Lipids: administered as fat emulsion solution, used when on IV for >3days. Balance nutritional needs; given every few days to clients on TPN.

Safe admin

C: Potassium: biggest baddest; it’s fussy. It mostly lives intracellular [20x higher level inside cells, serum level is very low] Stare at K+ levels on lab values first, b/c the heart is sensitive to K+. Renal pts: hyperkalemia: why don’t they have dysrhythmias? Because they are dialyzed, and the change in K is slow w/ renal failure. If you give diuretics and you shift the K+ quickly, the heart gets really pissed off.

Prototype: Micro K
Use: who gets it? Correct potassium deficit: strengthen cardiac and muscle contraction. P At risk for hypokalemia: People on potassium wasting diuretics, loops, thiazides, etc. [HTN and CHF’ers.]
Action: Transmits and conducts nerve impulses, contracts all 3 muscle types…except for the love muscle.
Adherence to regimen: The liquid tastes nasty and the pills are big.
Adverse: life threatening: dysrhythmias, resp distress, cardiac arrest.

hypokalemia: nausea, vomiting, dysrhythmias, soft flabby muscles
hyperkalemia: nausea, decreased urine output, tachycardia, then bradycardia, weak muscles

Don’t have to know this:
To Quickly drop K+ levels: Can adjust with a certain “K-exylate” enema that pulls K+ out. Insulin and 10% dextrose will also drop K+. Also Kayexulate will pull down super high levels of K.

D: Sodium:
Hypernatremia: flushed skin, elevated body, higher BP
Hyponatremia: lost Na+ with vomiting/diarrhea. Neurons don’t like this—confusion can occur. People who over drink water will lose Na+.

E: Calcium: lives in the bones largely. Need to assess Ca+ level. Calcium promotes normal nerve and muscle actions; prevents clotting, important for forming bone and teeth. Osteoporosis hits women hard, esp. postmenopausal. Free calcium is bound to proteins, the rest is unbound and can cause physiologic changes.
Hypocalcemia: calcium leaves the bone to balance body needs, risk for fractures. Causes: hypoparathyroidism, vit D deficiency, multiple blood transfusions. Symptoms; tetany, spasms, convulsions.
Hypercalcemia: from hyperparathyroidism, hypophosphatemia, bone cancer, thiazides, fractures.
Calcium Carbonate is “tums.” People get this when they are at risk for hypo or hyper calcemia

F: Magnesium: promotes transmit of neuromuscular activity, mediates NS transmission in CNS. Promotes cardiac muscle contractility [like K], activates enzymes for metabolism of carbs, protein.
Hypomagnesemia: often in combination with K or Ca deficits. Increases release of ACh, increasing neuromuscular excitability.
Hypermagnesemia: don’t know what happens

Our job forever and ever is to check electrolyte levels.

III: NUTRITIONAL SUPPORT:

Enteral vs parenteral
Our job w/ tube feedings: ensure it’s flowing, placement, residuals, assume nothing! Flush the lines: tube replacement is a pain, and it’s preventable.

1: Routes: Feeding tubes: G, J, NG. There are certain tube feedings specified for certain illnesses.

2: Solutions: vary based on the pt’s needs. The rates may vary based on tolerance, rate of output by the patient [think poop…], etc. Doc and dietician pick which solution.

3: Methods of delivery:
Bolus: not great. 200-400 mL at once delivered 6x/day via syringe or funnel. Not tolerated well w/ ill people, but it doesn’t require technology.
Intermittent Enteral feedings: 300-400mL of solution Q 3 or 6 hrs over 30-60 minutes by gravity drip or pump.
Continuous feedings: critical pts, pts receiving feeding direct to sm. Intestine. Little bits at a time: 50-125 mL/hr.
Cyclic feeding: delivered over 8-16 hours daily, during night or during the day depending on the client’s activity level during day or night [more activity is a good time to have tube feeding off.

4: Complications of enteral nutrition: Dehydration risk, diarrhea [liquid in, liquid out]

Enteral Meds: supplemental pancreatic enzymes must be given enterically [is that a real word?], PO meds can usually be given via feeding tubes once dissolved
1: Calculations of doses: doc over stock times vehicle, same as all the other conversions
2: Delivery: via the tube…right?

TPN: given via a central line. Usually high %dextrose [30-40] via a Central Venous Pressure, a PICC, etc.
PICC: peripherally inserted central catheter [straight to the heart]. For Chemo, long term I V therapy. You can’t give these high concentrations peripherally.

1: Ingredients: high dextrose solutions, probably some aminos, lipids…the book really doesn’t say.

2: Complications:
A: Catheter insertion: Bad things from catheter insertion: pleural poke [that’s your lung, that’s bad], damage or perforation of vein, infection
B: Infusion: Air bubbles from sloppy hanging of solution, hypervolemia from osmotic pull into the blood vessels. You care about blood sugars; TPN pts have high blood sugars, sometimes low blood sugars when TPN is stopped abruptly.

Case scenario: TBI pt w/ G Tube…don’t really need to check placement, but we have to flush it, check site for infection, change dressing, check residuals, esp right away at beginning of shift.

God I’m so glad I actually finished this…happy we’re done with another Pharma Exam Day!